IQ criteria updates

• Effective May 1, 2024 – IQ criteria updates to the CP:Procedures Reduction Mammoplasty Male and Adolescent subset
• Effective May 1, 2024 – IQ criteria updates to the CP:Procedures BRCA1 and BRCA2 in Hereditary Cancer  subset

Mastectomy treatment, breast reconstruction, and hospital stays mandates

• Effective May 1, 2024 – CPT code 11971 will not require prior authorization when related to reconstruction due to breast cancer, represented by ICD-10 diagnosis codes C50.011-C50.929; C79.81; D05.00-D05.92; Z42.1; Z85.3. For full details related to this policy, please click here.

Ambulance – Air and water transport

• Effective January 17, 2024 – The policy statement section, which was inadvertently removed, was placed back into this medical policy with no changes. For full details related to this policy, please click here.

Glucose monitoring – Home – Non-OneTouch brand                    

• Effective May 1, 2024 – The OneTouch Verio® Sync Meter will be removed from the list of covered OneTouch meters for Medicare Advantage plans, as this meter is no longer being distributed. For full details related to this policy, please click here. 

Mammograms and pap smears mandate policy 

• Effective January 1, 2024 – RI legislature requires a coverage mandate addressing mammogram screening services when dense breast tissue exists.

Any screening deemed medically necessary for proper breast cancer screening in

accordance with applicable American College of Radiology guidelines including, 

but not limited to, magnetic resonance imaging, ultrasound, or molecular breast imaging

for any person who has received notice pursuant to § 23-12.9-2 of the existence of dense breast tissue.

Per the advice of legal, the state mandate addresses coverage of breast screening services which can have copays and pre-auth requirements where applicable. These services will remain excluded from preventative benefits. For full details related to this policy, please click here.

Physical and occupational therapy payment policy update

Updated policy effective as of January 1, 2024 to do away with the requirement of having an “ordering physician” for PT/OT services. This policy change was decided for our members to have better accessibility to PT/OT services. For full details related to this policy, please click here.

Expanded Fertility Services

Effective April 1, 2024, this new policy outlines coverages for fertility services under a new optional benefit that will become available on April 1, 2024, for self-insured Commercial Products. For full details related to this policy, please click here. 

Genetic Testing Services

Effective May 1, 2024, several CPT codes in the Genetic Testing Services policy will have prior authorization removed for Medicare Advantage Plans and Commercial Products. The codes are as follows: 

• 81162 – 81167, 81206 – 81208, 81210, 81212, 81215 – 81217, 81261 – 81264, 81340 – 81342: These codes will change to medically necessary or not covered for Medicare Advantage Plans and not medically necessary for Commercial Products based on ICD-10-CD diagnosis coding.
• 81265 – 81268: These codes will change to covered services.
• 81270: The authorization of this code will be modified, and authorization will be needed for any diagnosis code other than the following: D45, D47.3 and D75.1. 
• 81240 and 81241: These codes will change to Not Covered for Medicare Advantage Plans and Not Medically Necessary for Commercial Products.

Additionally, there is an update to the Medical Criteria in this policy related to not having previous carrier screening. 

For full details related to this policy, please click here.